Person(s) to contact in case of Emergency / Authorized to pick up child:

First Contact

Second Contact

Relationship

Relationship

Home Phone

Home Phone

Work Phone

Work Phone

Names of Children in family:

Name:

Birthdate:

DayMonthYear

Name:

Birthdate

DayMonthYear

Name:

Birthdate

DayMonthYear

Has child had previous experience away from home?

Are you Child's immunizations up to date?

If no please explain:

Child's Health History

Health Problems

If Yes please upload documentation

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Check an of the following illnesses the child has had:

Asthma

Eczema

Croup

Diphtheria

Earaches

Pneumonia

Convulsions

Tonsillitis

Mumps

Polio

Measles

Whooping Cough

Chicken Pox

Influenza

Bronchitis

Frequent Colds

Rheumatic Fever

Does you child have any known allergies?

if Yes, what are they and what are your child's reactions:

Does your child take any medication on a regular basis?

If Yes please list the names of the medications and the medical condition for which it is taken:

Please comment on any other medical information or special need the child care provider should be aware of:

I authorize the child care provider/staff to obtain the following services for this child if necessary: Public Health Nurse, Physician and or Ambulance in the event of an emergency. (Ambulance fees and/or health care costs are the responsibility of the parent/guardian.)